How gamification strategies can support FQHC engagement in value-based care contracts

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Over the course of a weekday morning, someone unlocks access to bonus content while playing a game on their phone. A Head of Department orders coffee for her whole team, earning a windfall of reward tokens. Dozens of buyers think about which credit card to use for purchases so they can maximize rewards points and cash back bonuses. Across the board, the expectation of instant gratification is consistently met.

As the day unfolds, a patient remembers he has an afternoon doctor’s appointment at his Community Health Center (CHC) and makes a mental note to check in online. His physician looks over her packed clinic schedule and sees that the CHC has a handful of complex cases that day. Her nurse sees that two of the day’s patients will likely have more intense documentation and referral needs than others, which will need to be double-checked in order make sure value-based care (VBC) targets are met.

The patient

Preparing for the afternoon appointment starts out with a small win – remembering the password needed to access the patient portal on the second try averts an hour-long lockout for security purposes. Sadly, it’s a bittersweet victory. Almost immediately, you’re reminded that your flu shot is overdue, you need to schedule a physical and there’s a balance due on your account, along with five forms you were supposed to fill out at least 24 hours before the appointment you have in 13 minutes.

The physician

Years after a freak accident, your 3:00 PM patient is still experiencing terrible migraines and nausea. Preexisting conditions also play a role, though, and trying to figure out what’s going on is a challenge you’re keen to solve. In thinking about how best to document the case, you remember that you need to double-check that all the labs and referrals for your earlier patient with diabetes have been ordered.

The nurse

It’s a fairly efficient day in clinic. For the most part, you’ve gotten the information you need to address patients’ needs before they head out the door. But for a few, there are lingering care gaps to close. The physician still needs to order an A1C test for a patient who left an hour ago – and refer him to endocrinology because of his poorly controlled diabetes. You’ll have to circle back with your colleague to confirm that these pieces of information are correctly documented and ordered before marking the encounter as complete in the patient’s chart.

The EHR

While technology-enabled products outside of healthcare have embraced the concept of gamification – those credit card points, coffee tokens and bonus pieces of content – electronic health records (EHRs) and other health IT systems have lagged behind.

But it’s largely because early EHRs – at the time, more commonly known as Practice Management Systems – were designed to serve the binary, computer-based needs of the billing and coding teams. This prototype of the EHR we know today solved a specific problem – and did it well.

So well, in fact, that other departments wanted to get in on the action. But rather than redesign the systems so they would better meet the nuanced needs of a larger population, the ability to document clinical cases was tacked onto Practice Management Systems, morphing into jury-rigged EHRs that were good enough, but never great.

At the core sat the same rudimentary prototype system making billing and coding functions run smoothly. Meanwhile, more sophisticated apps and specialized interfaces were tacked on top the initial model – reliant on it, yet often operating like separate entities.

Structural integrity

Ideally, the EHR would function like the structure at the beginning of a Jenga game – solid and stable, with all the blocks supporting overall function. Too often, though, products tacked onto existing workflows are akin to the final blocks removed from the game tower and placed on higher levels. As it becomes more and more top heavy, you hope your move won’t make the tower tumble. But even when you’re lucky, watching the next player’s move is still nerve-racking.

Because once the EHR tower tumbles, catastrophes can occur.

Products that don’t work with the EHR’s underlying billing and coding structure create workflows where providers can easily miss important information, where managing patient data becomes nearly impossible and where clinicians struggle with death by 1,000 clicks just to get the bare minimum done. Quality metrics become a chore to manage. Assessing concomitant and chronic clinical concerns is like trying to complete a puzzle with only half the pieces. Care management suffers. So do patient outcomes.

Gaming the system

There’s no universal list detailing what’s considered a chore. Dishes might be a hated nemesis, yet vacuuming feels meditative. But no matter what task is dreaded, one of the most efficient ways to get it done is through incentives. An extra life in a video game. Bonus miles for purchasing flights with your airline credit card. A free coffee or salad after making a set number of purchases.

The same mindset applies to payers – just ask the federal government. The Centers for Medicare & Medicaid Services (CMS) rewards health plans with a 5% revenue bonus if they achieve a Star Rating of four or higher. So, while few would say that making sure risk adjustment coding is supported by clinical documentation or closing gaps to goals for Quality metrics are why they went into medicine, attending to these tasks is what makes the gears of the system turn.

As humans, we’re wired to want rewards– whether they’re tokens for free coffee or risk adjustment merit badges. On a smartphone or a patient chart, user behavior works the same way. But when rote tasks like completing risk adjustment documentation, taking extra time to enter data about Quality metrics or checking off several value-based care tasks are rewarded with game-based incentives, suddenly the mundane becomes the challenging.

And when these lackluster tasks become enticing – even engaging – care improves. FQHCs can be more successful in their value-based care contracts because gamified incentives make completing the administrative tasks that directly impact reimbursement rates much more engaging and exciting. Resource allocation becomes more appropriate. Early intervention begins to help slow disease progression. Physician burnout decreases while financial reimbursement increases.